Motor Accident Medical Report This form is Approved Form AF2014-58, approved on 26 August 2014 by Karen Doran, delegate of the director-general, under section 276 of the Road Transport (Third-Party Insurance) Act 2008. As prescribed by section 84 (2)(d) of the Road Transport (Third-Party Insurance) Act 2008.
Part A: Patient's information Title
Mr
Mrs
Ms
Miss
Dr
Other Full Name Street Address Date of Birth
Medicare number
Date of Accident
Part B: Medical Information (To be completed by your doctor) Date of examination
Are the injuries consistent with the circumstances of the motor accident described to you?
Yes
No
Has the patient been treated for a similar condition or had an injury to the same area in the past?
Yes
No
Yes
No
Medical diagnosis or description of injury
Clinical findings (Symptoms, results of any investigations)
How long has the patient attended the practice? If yes, give details?
Did the patient require an ambulance?
Yes
No
Did the patient attend hospital?
Was the patient admitted to hospital?
Yes
No
Name of Hospital (if patient attended or was admitted)?
Authorised by the ACT Parliamentary Counsel—also accessible at www.legislation.act.gov.au
Is treatment likely to be required
Short term (6 weeks)
Medium term (6-12 weeks)
Long term (>12 weeks)
No treatment necessary
Treatment type
GP Management
Allied Health Therapy
Specialist
Other
Detail of treatment (including detail of treatment/ rehabilitation already undertaken)
Name of Provider
Contact Number
Patient's fitness for work Unfit for work from:
until:
Fit to resume normal duties with restrictions on:
Restrictions
Date of next review:
Fit to resume normal duties on:
Medical Practitioner's information Doctor's name
Work phone number
Area of specialty Provider number Address of practice
I declare that I am a registered medical practitioner and to the best of my knowledge the information provided here is true and correct. Signature of medical practitioner
Date
Authorised by the ACT Parliamentary Counsel—also accessible at www.legislation.act.gov.au
Protection of Privacy The information collected by this Motor Accident Medical Report, and throughout the course of your claim, is collected in accordance with the Road Transport (Third-Party Insurance) Act 2008 (the Act) and Road Transport (Third-Party Insurance) Regulation 2008 (the Regulation). The information is collected so as to encourage the speedy resolution of personal injury claims resulting from motor vehicle accidents, and to help the administration of the statutory insurance scheme and the detection of fraud. The information collected by this Motor Accident Medical Report and throughout the course of your claim, may be disclosed in accordance with the Act and the Regulation to such bodies as, the CTP regulator, the Nominal Defendant, and other insurers or parties involved in the assessment of your claim, such as those indicated below. Failure to provide all or part of the information may delay or prevent the assessment of your claim. You are able to gain access to personal information held as provided by the Privacy Act 1988 (Cth), or if the information is held by the Australian Capital Territory Government, you are able to gain access to the information as provided by the road transport legislation. Any personal information you provide to the CTP Insurer will be collected, held, used and disclosed in accordance with their Privacy Policy. You will be able to view their privacy policy on their website or you can request that the Insurer send you a copy.
Authorised by the ACT Parliamentary Counsel—also accessible at www.legislation.act.gov.au